The New Kidney-Focused Companies: A Privatized Approach to Value-Based Care and Addressing Social Determinants of Health
Authors: Eugene Lin, Gaurav Dave, Abhijit V. Kshirsagar
Journal: Journal of the American Society of Nephrology (2022)

Background With the advent of value-based care (VBC) programs, public and private insurers have kickstarted a commercial market in population health management.1,2 The new VBC companies outline goals of promoting high-quality, cost-efficient, and holistic health care, with several exclusively focused on kidney disease (Table 1). They seek to transform kidney health by offering new care pathways for nephrology providers, health care systems, payers, and patients, and profits for their investors through improved clinical outcomes. This article weighs the expected benefits with potential risks for stakeholders through the lens of potentially addressing the adverse social determinants of health (SDOH) associated with kidney disease. Table 1. - Selected characteristics of the current kidney-VBC companies Name of Company (url) Year Founded Location(s) Current Partners Cricket Health (https://www.crickethealth.com/) 2015 San Francisco, Massachusetts, Texas Fresenius Health PartnersInterwell Health, Cigna, Baylor Scott & White Health Plan Monogram Health (https://www.monogramhealth.com/) 2019 Southern United States (Tennessee) Cigna, Humana Reach Kidney Care (https://www.reachkidneycare.org/) 2011 a Southern United States, New Jersey, New York, Pennsylvania, Ohio, Missouri, Montana Humana Somatus (https://somatus.com/) 2016 Washington DC, East Coast, Southern United States Anthem, BlueCross BlueShield Tennessee Strive Health (https://www.strivehealth.com/) 2018 Missouri, Pennsylvania, North Carolina Bon Secours Mercy Health, SSM Health, b Humana, various BlueCross BlueShield health plans, c NANI d Evergreen Nephrology (https://evergreennephrology.com/) 2021 Tennessee RenalCare Associates, University of Pennsylvania, Colorado Kidney Care According to their websites, Cricket Health and Strive Health explicitly participate in VBC contracting, either as part of the Comprehensive Kidney Care Contracting or as part of the ESRD Treatment Choices program.aInitially started as a kidney education program in 2011.bSisters of St. Mary.cOregon, Utah, Idaho, and select counties in Washington, southeastern Pennsylvania, North Carolina.dNephrology Associates of Northern Illinois and Northern Indiana. How The Companies Work The new kidney-VBC companies concentrate on patients with advanced CKD, primarily stages 4 and 5, and emphasize slowing progression through education and enhanced access to care. They guide patients to home dialysis and kidney transplantation, which are historically underutilized. These kidney-VBC companies engage patients with in-person and telehealth encounters through interdisciplinary teams (e.g., advanced care practitioners, dietitians, pharmacists, social workers) supervised by a nephrologist and proprietary software. Thus, the team has the broad-ranging expertise to advise healthy food choices, reconcile medications, coordinate transplantation, schedule follow-up after complex hospitalizations, and communicate with all providers. The software can be critical in at least two ways: identifying patients at risk for poor outcomes and targeting effective therapeutic interventions. In a fee-for-service system, nephrologists lack incentives to develop a costly "kidney-focused" infrastructure, or to contract with these kidney-VBC companies. The business case for engagement stems from VBC arrangements, which incentivize high-quality, cost-efficient care.3 VBC models compare the total health care spending of the provider's patient panel to a risk-adjusted, projected benchmark. Providers either receive a percentage of the net savings ("shared savings") if they are less costly than the benchmark, or are penalized a portion of the net loss ("shared losses") if more expensive. To qualify for shared savings, the providers must also perform well on a battery of quality measures. Once providers are financially accountable for expensive complications such as hospitalizations, they have an impetus to invest in a care-coordination infrastructure. Kidney-VBC companies step into this market by contracting with insurers or payers, hospital systems, or large nephrology practices to absorb some of this risk in exchange for their population management infrastructure. The kidney-VBC companies profit if their upfront technologic and human capital investment yield downstream shared savings. The Centers for Medicare and Medicaid Services has >50 VBC models. The three models most relevant to kidney disease are the Medicare Shared Savings Program (MSSP), the Comprehensive Kidney Care Contracting model (CKCC), and the Kidney Care First model. The MSSP and CKCC hold providers accountable for shared savings and losses; the MSSP applies to a provider's entire Medicare population, whereas the CKCC focuses on kidney disease. Kidney Care First, which also focuses on kidney disease, assesses providers' costs, but does not formally do so with shared savings and losses. Kidney-specific models have encouraged providers, hospital systems, and payors to increase engagement with kidney-specific VBC companies. As an added incentive to improve care, the ESKD Treatment Choices model has mandatory participation for one third of the country, and financially incentivizes increased home dialysis and transplant waitlisting. Expected Benefits Multidisciplinary teams can potentially connect siloed CKD care that annually costs nearly US$138 billion in Medicare alone.4 Late-stage CKD care often requires intensive management from inpatient and outpatient providers as patients near kidney failure. The dialysis clinic becomes another site after initiating KRT. Although nephrologists act as primary providers for patients receiving dialysis, they do not receive incentives to coordinate multidisciplinary care with VBC. The kidney-VBC companies may be uniquely positioned to address health equity. The multidisciplinary care teams can help patients with relevant adverse SDOH, and provide education on optimal diet, access to healthy food areas, and KRT options. Patients often lack support to clear the many hurdles for transplantation or home dialysis.5 Some kidney-VBC companies provide transportation to and from providers, a critical need in under-resourced areas. Poverty and adverse SDOH can worsen CKD and its poor outcomes,5 and are mutually reinforcing.6 Improving CKD outcomes interrupts this vicious cycle. Thus, these multidisciplinary teams could yield long-term benefits for patients and communities traditionally left behind. By coordinating care and expanding access, the kidney-VBC companies should optimize transition to KRT by increasing the very low rates of home dialysis (10% of patients initiating KRT) and pre-emptive transplant (2%)4 and by reducing the frequency of patients starting dialysis in the hospital. Potential Risks Even in the VBC context, overcoming barriers in underserved areas might remain unprofitable. Addressing the neighborhood context may require more resources than the kidney-VBC companies can provide. Even with multidisciplinary care, patients living in poor communities may be unable to adopt lifestyle or diet recommendations because of inadequate green space or food deserts.7 These same areas frequently lack access to home dialysis and transplantation centers. Privatization does not necessarily prioritize links to local community resources that are critical to self-care.8 Additionally, nephrologists are navigating two concurrent experiments: public and private payers are actively testing the efficacy of VBC, and kidney-VBC companies are testing their products. Because most nephrologists often cannot build the required multidisciplinary infrastructure, many must contract with a private company touting an untested product. The sheer number of kidney-VBC companies (Table 1) ensures a fragmented marketplace with unclear interoperability, making the decisions for users fraught with financial risk. Given the rapid reimbursement cycles of VBC arrangements (typically 6–12 months), nephrologists cannot afford to pick an unsuccessful product. They will face the daunting task of evaluating companies ex ante, with little to no information. Unproven ventures may be particularly catastrophic to safety-net providers that cannot backstop significant losses. Ironically, the VBC revolution would exacerbate poor health outcomes associated with SDOH if safety-net providers disproportionately go bankrupt. Moreover, the kidney-VBC companies may disrupt existing relationships between patients and providers. If well implemented, multidisciplinary teams add an extra layer of supervision while streamlining care. However, the teams could fragment care and confuse patients about who is directing care, if poorly implemented. Kidney-VBC companies that directly contract with payers might circumvent the traditional provider-patient relationship, or worse, introduce confusing mixed messages to patients. Although multidisciplinary care is effective in improving outcomes in other resource-intense populations,9 evidence of its financial feasibility is limited to a simulation study in kidney disease.10 The patient-provider relationship is already tenuous in underserved communities, where patients' prior experiences understandably lead to a distrust of the health care system. Explicitly tying medical care to profits, a key goal for the kidney-VBC companies and investors, could further erode the trust. Conclusions Finally, kidney-VBC companies do not have many regulatory guardrails. For instance, they are not bound by regulations preventing "cherry-picking" or "lemon-dropping." The companies also might focus on strategic upcoding rather than improving care. Even payments introduced to improve equity (e.g., the Health Equity Incentive in the ESRD Treatment Choices) may not be enough to sway the companies to address adverse SDOH. Private companies are also generally loathe to share proprietary business practices and, without adequate regulation, will likely opt to keep their performance on quality measures opaque. To the extent that data sharing reduces a company's advantage in the marketplace, regulators must also ensure regulation does not dampen overall innovation in VBC. As VBC kidney care grows, regulators must hold kidney-VBC companies accountable for improving transitions of care, connecting silos, reducing costs, and addressing adverse SDOH. Policies that require greater transparency of outcomes, quality, costs, engagement with local community resources, and implementation would improve interoperability and accountability. Moreover, requiring reinvestment of a percentage of profits into infrastructure and a minimum percentage of dually eligible (Medicare or Medicaid) enrollees could help address structural inequities. Because kidney disease disproportionately affects patients with high adverse SDOH, policymakers must ensure the VBC revolution does not leave them behind.